Hirschsprung disease

Practical points in surgical pathology

Juan Putra, MD
Department of Pathology
Boston Children’s Hospital/ Harvard Medical School
 Background
• Hirschsprung disease (HD): congenital absence of
ganglion cells in the myenteric and submucosal
plexuses of the terminal rectum and a highly variable
length of contiguous proximal bowel

• The resulting aganglionic segment of the colon fails

to relax, causing a functional obstruction

• Prevalence rate: 1 in 5000 newborns

Background

Goldstein AM et al. Clin Genet. 2013; 83(4):307-316

Uptodate.com, accessed on 2/11/18
Uptodate.com, accessed on 2/11/18
 Background
• Classification:
– Ultrashort (distal-most rectum)
– Short (rectosigmoid) 80% of patients; M:F = 4:1
– Colonic (desceding colon)
– Long-segment (proximal to splenic flexure)
– Total colonic aganglionosis
Uptodate.com, accessed on 1/30/18
 Timeline – pathology specimens

Intraoperative Pull-through
seromuscular biopsies resection specimen

Surgery

Symptoms Diagnosis Failed pull-

through
Rectal suction biopsy
Biopsy/resection
Rectal suction biopsies
 Rectal suction biopsies
• Rectal tissue (obtained from multiple levels):
– Fresh tissue:
• 1 H&E section (orientation)
• Acetylcholinesterase (3 sections)
– Formalin:
• H&E sections
– Raj Kapur (Surgical Pathology Clinics, 2010): at least 5 slides
with 12-20 sections/slide
• Calretinin immunostain
 Adequacy:
1. Biopsies should be taken 1
to 2.5 cm proximal to
anorectal
squamocolumnar junction
(no squamous mucosa!)
2. The specimen should
measure at least 3 mm
and a minimum of a third
of the biopsy should
include submucosa

Kapur RP. “Internal motor disorders”. Pathology of Pediatric Gastrointestinal and Liver Disease. New York: Springer, 2014.
 Mature ganglion cells

Immature ganglion cells

Lymphocytes and
endothelial cells

Kapur RP. “Internal motor disorders”. Pathology of Pediatric Gastrointestinal and Liver Disease. New York: Springer, 2014.
Hypertrophic nerve (>40μm)

Kapur RP. “Internal motor disorders”. Pathology of Pediatric Gastrointestinal and Liver Disease. New York: Springer, 2014.
Acetylcholinesterase

Kapur RP. Pediatric and Developmental Pathology. 2017; 20(4):308–320

 Calretinin

Kapur RP. “Internal motor disorders”. Pathology of Pediatric Gastrointestinal and Liver Disease. New York: Springer, 2014.
 Pitfalls
• Failure to examine as many sections as
possible from rectal biopsies may lead to a
false-positive diagnosis of HD
• Hypertrophic submucosal nerves are not
present in all aganglionic biopsies from HD
• Recognition of immature ganglion cells in
H&E-stained sections requires experience
Intraoperative evaluation
 Intra-operative evaluation

• Seromuscular biopsies:
– Level from with the biopsy was taken should be indicated
– Orientation such that the two muscle layers can be easily
distinguished
– Ribbon of serial sections (>3 sections) is cut and stained
with H&E
• Raj Kapur (Surgical Pathology Clinics, 2010): 10 or fewer
 Intra-operative report
• Readily identifiable ganglion cells with
associated neuropil and no nerves

• Intraoperative seromuscular biopsy from

(level):
– Fully ganglionic
 Intra-operative report
• Ganglion cells are present but are
accompanied by hypertrophic nerves

• Intraoperative seromuscular biopsy from

(level):
– Transitional zone; (biopsy from proximal level
advised)
 Intra-operative report
• Ganglion cells appear sparse (clusters are
small or more widely spaced than usual)

• Intraoperative seromuscular biopsy from

(level):
– Ganglion cells present but appear reduced in
number. Possible transitional zone; (biopsy from
proximal level advised)
 Intra-operative report
• Ganglion cells are absent and there are
hypertrophic nerves

• Intraoperative seromuscular biopsy from

(level):
– No ganglion cells present. Hypertrophic nerves.
(biopsy from proximal level advised)
 Intra-operative report
• Ganglion cells are absent. No hypertrophic nerves
and the muscle layers are closely apposed

• Intraoperative seromuscular biopsy from (level):

– No ganglion cells present. No hypertrophic nerves.
Closely apposed muscle layers, suggestive of long
segment disease or total colonic aganglionosis;
(biopsy from proximal level advised)
Colonic resection
 Colonic resection

Kapur RP. “Internal motor disorders”. Pathology of Pediatric Gastrointestinal and Liver Disease. New York: Springer, 2014.
 Transitional zone
Euganglionic Transitional zone

Kapur RP. “Internal motor disorders”. Pathology of Pediatric Gastrointestinal and Liver Disease. New York: Springer, 2014.
 Transitional zone

Eosinophilic ganglioneuritis Adventitial fibromuscular dysplasia

Kapur R. Seminars in Pediatric Surgery (2012) 21, 291-301

 Distal
Proximal
Biopsy sites
Proximal

Distal
 Pathology report example
• Distal rectum, resection:
– Distal aganglionic segment of 5 cm, and
normoganglionosis of the most proximal 8 cm of the
specimen, consistent with Hirschsprung's disease

Ganglionic Aganglionic

Distal

Proximal
Postoperative persistent
obstructive symptoms
 Differential diagnosis
• Failure to resect the all of the anatomically abnormal
bowel (transitional zone pull-through)
• Anastomotic strictures
• Poorly-understood physiologic defects of
euganglionic bowel
• Acquired aganglionosis (regional ischemia)
Hirschsprung-associated enterocolitis
A lethal complication of Hirschsprung disease
 Clinical features
• Abdominal distension
• Explosive diarrhea
• Vomiting
• Fever
• Shock
• Lethargy
• Occasionally perforation of bowel proximal to
aganglionic segment
 Hirschsprung-associated enterocolitis
• Highest risk for development:
– Before diagnosis of HD
– Following definitive pull-through procedure (seen
within 2 years after the procedure)

• Histology:
– Normal, mucin retention
– Cryptitis, crypt abscess
– Fibrinopurulent exudate and mucosal ulceration
– Transluminal necrosis or perforation
 The future?

Choline transporter IHC to replace

acetylcholinesterase stain
Kapur RP. Pediatric and Developmental Pathology. 2017; 20(4):308–320
Kapur RP. Pediatric and Developmental Pathology. 2017; 20(4):308–320
 Summary
• Start with specimen adequacy!
• Features of Hirschsprung disease:
– Lack of ganglion cells
• Auerbach’s and Meissner’s plexuses
– Hypertrophic nerve
– Ancillary studies
• Acetylcholinesterase and calretinin stains
• Caveats:
– Immature ganglion cells
– Transitional zone
Thank you